The effect of obstructive jaundice on the sensitivity of intravenous anesthetic of remimazolam: study protocol for a controlled multicenter trial

Background It is well known that obstructive jaundice could affect the pharmacodynamics of some anesthetics, and the sensitivity of some anesthetics would increase among icteric patients. Remimazolam is a new ultra-short-acting intravenous benzodiazepine sedative/anesthetic, which is a high-selective and affinity ligand for the benzodiazepine site on the GABAA receptor. However, no study has reported the pharmacodynamics of remimazolam in patients with obstructive jaundice. We hypothesize that obstructive jaundice affects the pharmacodynamics of remimazolam, and the sensitivity of remimazolam increases among icteric patients. Methods/design The study will be performed as a prospective, controlled, multicenter trial. The study design is a comparison of remimazolam requirements to reach a bispectral index of 50 in patients with obstructive jaundice versus non-jaundiced patients with chronic cholecystitisor intrahepatic bile duct stones. Remimazolam was infused at 6 mg/kg/h until this endpoint was reached. Discussion Remimazolam could be suitable for anesthesia of patients with obstructive jaundice, because remimazolam is not biotransformed in the liver. Hyperbilirubinemia has been well-described to have toxic effects on the brain, which causes the increasing of sensitivity to some anesthetics, such as desflurane, isoflurane, and etomidate. Furthermore, remimazolam and etomidate have the same mechanism of action when exerting an anesthetic effect. We aim to demonstrate that obstructive jaundice affects the pharmacodynamics of remimazolam, and the dose of remimazolam when administered to patients with obstructive jaundice should be modified. Trial registration Chinese Clinical Trial Registry ChiCTR2100043585. Registered on 23 February 2021

Safe perioperative management of major hepatectomy in a patient with portal hypertension after elimination of hepatitis C: a case report

Background The administration of direct-acting antiviral agents in patients with liver cirrhosis and hepatitis C has been shown to improve liver function and long-term prognosis after sustained virological response (SVR) is achieved. However, in patients with portal hypertension (PH) at the time of SVR, PH may persist despite improvement in liver function. Case presentation An 82-year-old woman with liver cirrhosis due to hepatitis C was treated with direct-acting antiviral agents and achieved SVR. During follow-up, computed tomography revealed a low-density tumor in the left lateral region of the liver with dilation of the left intrahepatic bile duct. Considering the patient’s advanced age and PH persistence with a mild decrease in liver reserve function after SVR, preoperative percutaneous transhepatic portal embolization (PTPE) and partial splenic embolization (PSE) were performed concomitantly. Laparoscopic left hemihepatectomy was performed 8 days after the PTPE and PSE. The patient was discharged 8 days after surgery without any postoperative complications. Conclusions Laparoscopic left hemihepatectomy after preoperative management of PH was performed safely in a patient after the elimination of hepatitis C.

Etiology and outcome of neonatal cholestasis: an experience in a tertiary center of Bangladesh

Background Neonatal cholestasis (NC) is a major cause of morbidity and mortality in young infants. This study examines the etiology of NC and its outcome during 2 years of follow-up at a tertiary referral center in Bangladesh. Results Out of 80 cholestatic infants, 60% had intrahepatic cholestasis with a mean age of onset of 12.4±2.8 days and a mean age of admission of 82.4±29.0 days. The remaining 40% were extrahepatic with a mean age of onset of 6.7±2.3 days and a mean age of admission of 94.6±50.4 days. Biliary atresia (BA), idiopathic neonatal hepatitis (INH), and TORCH (Toxoplasma, rubella, cytomegalovirus, and herpes simplex) infection except rubella were the most common causes. After receiving treatment, 46.2% of the cases improved, 23.8% deteriorated with morbidity, and 30% died. The majority of the children with INH, TORCH, choledochal cyst, hypothyroidism, galactosemia, and urinary tract infection (UTI) with sepsis were improved. Significant mortality was found in BA (56.6%), intrahepatic bile duct paucity (PIBD) (100%), and progressive familial intrahepatic cholestasis (PFIC) (100%) whereas the rest of BA (43.4%) live with persistent morbidity. Significant clinical improvement was observed in 37 (46.2%) cases of cholestasis evidenced by decreasing jaundice, change of color of urine from dark to normal color, change of stool color from pale to yellow, and gradual decrease in liver size from hepatomegaly state. In addition, decreasing median total bilirubin, direct bilirubin, alanine transaminase, gamma-glutamyl transferase, and alkaline phosphatase showed biochemical improvement at 2 years follow-up. The age of admission, etiology, and presence of ascites are the predictors of outcomes. Conclusion BA was the most common cause of extrahepatic while INH and TORCH infection were the most common cause of intrahepatic cholestasis. Majority of children with intrahepatic cholestasis improved but deteriorated with BA and genetic causes. Prompt referral and early diagnosis as well as the etiology of NC were the main determinants of the favorable outcome.

Imaging Features of Hepatocellular Carcinoma With Bile Duct Tumor Thrombus: A Multicenter Study

ObjectivesThere are still challenging problems in diagnosis of hepatocellular carcinoma (HCC) with bile duct tumor thrombus (BDTT) before operation. This study aimed to analyze the imaging features of HCC with B1–B3 BDTT.Materials and MethodsThe clinicopathological data and imaging findings of 30 HCC patients with B1–B3 BDTT from three high-volume institutions were retrospectively reviewed. A total of 631 patients without BDTT who were randomly collected from each of the enrolled centers were recorded as the control group to analyze the differences in clinicopathological characteristics and imaging features between the two groups. A total of 453 HCC patients who underwent surgical treatment in the three institutions from January 2020 to December 2020 were collected for a blinded reading test as the validation group.ResultsHCC patients with B1–B3 BDTT had more advanced tumor stages and adverse clinicopathological features. HCC lesions were detected in all patients, and intrahepatic bile duct dilation was observed in 28 (93.3%) patients with B1–B3 BDTT and 9 (1.43%) patients in HCC without BDTT. The intrahepatic bile duct dilation showed no enhancement at hepatic arterial phase (HAP) and no progressively delayed enhancement at portal venous phase (PVP), but it was more obvious at PVP on CT. In the reports of the 30 HCC patients with B1–B3 BDTT generated for the image when the scan was done, BDTT was observed in all 13 B3 patients and 3 of 12 B2 patients, but none of the 5 B1 patients. Fourteen patients were misdiagnosed before surgery. However, when using intrahepatic bile duct dilation in HCC patients as a potential biomarker for BDTT diagnosis, the sensitivity and specificity for BDTT diagnosis were 93.33% and 98.57%, respectively. The blinded reading test showed that intrahepatic bile duct dilation in CT and MRI scans could be for separating HCC patients with B1–B3 BDTT from HCC patients without BDTT.ConclusionsThe HCC lesions and intrahepatic bile duct dilation on CT or MRI scans are imaging features of HCC with BDTT, which might facilitate the early diagnosis of B1–B3 BDTT.

Surgical methods of treatment for cholecystolithiasis combined with choledocholithiasis: six years’ experience of a single institution

Introduction The optimal treatment of choledocholithiasis combined with cholecystolithiasis remains controversial. Common surgical methods vary among endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC), laparoscopic transcystic common bile duct exploration (LTCBDE), laparoscopic transductal common bile duct exploration (LCBDE) with or without T-tube drainage. The purpose of this study is to evaluate the safety and effectiveness of surgical methods and to determine the appropriate procedure for patients with cholecystolithiasis combined with choledocholithiasis. Methods From January 2013 to January 2019, a total of 1555 consecutive patients diagnosed with cholecystolithiasis combined with choledocholithiasis who underwent surgical treatment in Tongji Hospital were retrospectively analyzed. Total 521 patients with intrahepatic bile duct stones underwent LC + LCBDE + T-Tube were excluded from the analysis. At last, 1034 patients who met the inclusion criteria were divided into three groups according to their surgical methods: preoperative ERCP + subsequent LC (ERCP + LC group, n = 275), LC + LCBDE + intraoperative endoscopic nasobiliary drainage (ENBD) + primary duct closure (Tri-scope group, n = 479) and LC + laparoscopic transcystic CBD exploration (LTCBDE group, n = 280). Clinical records, operative findings and postoperative follow-up were collected and analyzed. Results There was no mortality in three groups. Common bile duct (CBD) stone clearance rate was 97.5% in ERCP + LC group, 98.7% in Tri-scope group, and 99.3% in LTCBDE group. There were no difference in terms of demographic characteristics, biochemistry findings and presentations, but the Tri-scope group had the biggest diameter and amount of stones and diameter of CBD, the LTCBDE group had the least CBD stones and the biggest diameter of cystic gall duct (CGD). ERCP + LC group have the longest hospital stay (14.16 ± 3.88 days vs 6.92 ± 1.71 days vs 10.74 ± 5.30 days, P < 0.05), also has the longest operative time than others (126.08 ± 42.79 min vs 92.31 ± 10.26 min, 99.09 ± 8.46 min, P < 0.05). Compared to ERCP + LC group, LTCBDE group and Tri-scope group had lower postoperation-leukocyte, shorter surgery duration and hospital stay (P < 0.05). Compared to the Tri-scope group, the LTCBDE group had the shorter hospital stay, extubation time and operation time and less intraoperative bleeding. There were less postoperative complications in LTCBDE group (1.1%) compared to the ERCP + LC group (3.6%) and Tri-scope group (2.2%). Follow-up time was 6 to 72 months. Four patients in ERCP + LC group and 5 in Tri-scope group reported recurrent stones. Conclusion All the three surgical methods are safe and effective. Tri-scope approach and LTCBDE approach have superiority to preoperative ERCP + LC. LC + LTCBDE shows priority over Tri-scope approach, but should be performed in selected patients. LC + LCBDE + T-Tube can be an alternative management if the other three procedures were failed. The surgeons should choose the most appropriate surgical procedure according to the preoperative examination results and intraoperative situation.

Diagnosis of a single gallbladder with double cystic ducts and dominant accessory duct draining into the right hepatic duct: a case report

Biliary anomalies are a high risk for biliary injury during surgery, and although a biliary anomaly is occasionally encountered, variations in cystic ducts are rare. A preoperative diagnosis is highly valuable in facilitating surgical procedures and avoiding surgical complications. Herein, the case of a 67-year-old female patient with acute cholecystitis, in which preoperative fluoroscopic cholangiography clearly demonstrated a single gallbladder with double cystic ducts, is presented. The accessory duct was found to be dominant, draining into the otherwise normal right intrahepatic bile duct, and laparoscopic cholecystectomy was performed smoothly and successfully. Fluoroscopic cholangiography is a powerful tool that may clearly depict the anomaly of a single gallbladder with double cystic ducts. Through appropriate preoperative knowledge and demonstration of this biliary anomaly in the present case, laparoscopic cholecystectomy was safely performed, and the patient was symptom-free at the 3-year follow-up assessment.

A Novel Cause of Biliary Peritonitis after Endoscopic Retrograde Cholangiopancreatography: Case Report and Literature Review

Background. Endoscopic retrograde cholangiopancreatography (ERCP) can lead to several complications such as duodenal or bile duct perforation. The incidence of pneumoperitoneum post-ERCP is rarely seen (<1%) and is associated with perforations of the duodenum or common bile duct in therapeutic ERCP after sphincterotomy. In this case, we disclose a novel cause of biliary peritonitis after ERCP. Case Presentation. A 65-year-old man presented with abdominal pain and distended abdomen after uneventful ERCP with sphincterotomy. An abdominal computed tomography (CT) was performed whose finding indicated duodenal perforation. The patient was rushed to an emergency laparotomy where only a rupture of an otherwise normal subcapsular intrahepatic bile duct was found. The surrounding liver parenchyma was healthy. The cause of this condition was probably post-ERCP pneumobilia and the increase of pressure in the biliary tract. Conclusions. This is the first case in literature describing the rupture of a subcapsular healthy bile duct as cause of biliary peritonitis after ERCP. This case also suggests that in the management of post-ERCP complications, the cooperation of radiologists and surgeons is vital for the patient’s wellbeing.

Clinical Characteristics of Choledochal Cysts With Intrahepatic Bile Duct Dilatations

Background: Whether the dilated intrahepatic bile duct (IHBD) has any effect on prognosis of choledochal cyst (CC) remains controversy. In the study, we aim to summarize the clinical characteristics and prognosis of those patients.Methods: A total of 192 children (47 males, 145 females) diagnosed with CC were identified in our hospital, including 127 without IHBD dilatation (group A) and 65 with IHBD dilatation (group B). A retrospective analysis was performed to explore the clinical characteristics of group B based on clinical indices, symptoms, and complications. Results: Compared with group A, incidences of jaundice and fever were significantly increased in group B (p=0.01 and 0.033, respectively). Preoperative total bilirubin (TB), direct bilirubin (DB), and indirect bilirubin (IDB) were also higher in group B than in group A (p=0.0052, 0.0005, and 0.0136, respectively), as were preoperative levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), gamma-glutamyl transferase (GGT), and total bile acid (TBA) (p=0.0057, 0.0250, 0.0002, and 0.0242, respectively). Early postoperative GGT levels in group B remained abnormal and were significantly higher than in group A (p=0.0003). The risk of liver fibrosis or cirrhosis was significantly increased for group B compared with group A (p=0.012) and also occurred earlier in group B (p<0.001), among them, dilated IHBDs recovered to normal in 89.23% (7/65) of patients. Meanwhile, the incidence of postoperative pancreatitis increased significantly in group B as well (p=0.003).Conclusion: CC with IHBD dilatation was associated with significantly increased preoperative bilirubin levels, abnormal liver function, and higher incidence of liver fibrosis or cirrhosis early in the disease course. Timely radical surgery is recommended for such patients and postoperative extinction of the IHBD dilatation occurs early in most of those patients.